Provider Demographics
NPI:1194792218
Name:BINGHAM, CHERYL DIANE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:DIANE
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11905 S CENTRAL AVE
Mailing Address - Street 2:#203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-2836
Mailing Address - Country:US
Mailing Address - Phone:323-564-7504
Mailing Address - Fax:323-564-8645
Practice Address - Street 1:11905 S CENTRAL AVE
Practice Address - Street 2:#203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-2836
Practice Address - Country:US
Practice Address - Phone:323-564-7504
Practice Address - Fax:323-564-8645
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0348181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB34818Medicaid